- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.46 / $112.25 / $134.30
| Professional | | $107.46 | $112.25 | $134.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.45 / $104.45 / $104.45
| Professional | | $104.45 | $104.45 | $104.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.83 / $31.83 / $52.03
| Professional | | $31.83 | $31.83 | $52.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.12 / $120.12 / $120.12
| Professional | | $120.12 | $120.12 | $120.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.53 / $64.95 / $116.37
| Professional | | $50.53 | $64.95 | $116.37 |